00040084DIVISION v PERMIT I CONTRACTOtR- INFORMATION: .�I pOOg00 fgp j1
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LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that l w licensed under previsions of Clutter 9(comneucing Job Description �L,L (/P't tlJ ATk;'�
with Swtim?(KXI of Division 3 of the Business am Pwfaaaitm Code, ate my license is L Esso of coon �S j l 1
mfullformandeffma. •� 81d /, S /G gy
Limnse a.a Lit, g �{, A L SAT H O 2 �•C W 1.
Dau Convector
ARCHITECT'S DECLARATION
und
1 understand my plans shall W used as public minds
Licensed Pmfessiow
OWNER -BUILDER DECLARATION
I hereby efma that 1 an, exempt from the Centimeter Limme, Law for the
following mason. (Section 7031.5, Bwitwas and Professions Cade: Any city or county
which swan a permit to construct. cher, improve, demoliah. or repair any squame
prig to is i.awna. alk requires the Wide.. for such pemtit to Elea signed.arcnamt
thin he is licensed Punwm e, the provisions of the Convamor. License Isco (Clap erg
(commencing with Section 7") of Division 3 ofthe Business and professions Cndc)or
that Im is exempt therefrom and the Buis for the .11cged csemphon. Any violation of
Smile. 7031.5 by any .,b., for a permit subjwa the applicam e, a civil pamalty of
not more than five hundred dollars 15500). '
0 I,mo ofdamopeny.mmycmploywwithwaguutheirwlccompenwtion.
will do the week, and the shouctme is trot intended in offeml fm aide (Sm. 7014, Busituu
and professions Codc: The Comenclmi License Law does not apply to an owner of
property who Wilda or improves thereon, and wed does such work himself or ducally,
his we employees. provided that such improvements arc int intended m offered fee
ssle. If. however, the building or improvement is sold within me ymr of completion, the
wmnWildee will have the burden of proving that he did not build or improve for Far,
pose of ale.).
I, as owner of the property, aat exclusively contracting with licensed comracon to
construes the project (Sae voaa, Business and Profeaions Code:) The Contractors Li.
c ace Isco deer, inn apply to an owner of property who Wilds or impooves thereon, ate
who contracts for such projects with acarmacter(O licensed punuanuo the Contractees
License law.
1 e n exempt under Sw. . B & P C fm this mason
Owner Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dwleratiaa:
❑ h have and will for by
a Cion 37W of the Labor
Code. for
for Worker's Compeer
work, r provided for mi Saxon 3]00 of the Labor Cede, for the performama of she
work have
which Nis permit is rawer.
1havead will ods,fmaintainWorker's ante of
thtn Imfonate.r which
h reqMoped by Swaion
3700of the IAWI Codas,for performance of dte wink for which Nis permit is issued.
My W L �MILrYvh pad Polcca nsmbnsart. J 0 1
Carrie •JTnIOra
t "I/l7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action rad not bekmplered ifthc pcmtit is forma, hundred dollen (5100)
or It's.)
I ramify that in the ado.c of the work for which this pantie is iaued.I shall
me employ any person in any manor so as to become a.bjwt te, the Warless' Compcn-
wtim Laws of Califomia. Date
Applicant
NMCE TO APPLICANT: If. after making this Certificate of Estmption, you slwuld
become subject to the Workers Compensation provisions of the Labor Cede. yon muss
forthwith comply with such provisions or this penny, shall be domed revoked.
CONSTRUCTION LENDING AGENCY
I hcrcby d(rre that them is a construction IeMing agency for sed d -. .f
the work for which this permit is issued (Soc. 3097, Ci, C.)
Lenders Name
Lender's Addmsr
I anify thin I have mrd this application and awe that the above information is
mrnwt, l agrtc to comply with all city and county ordinaaes and aunt laws nlming to
building onvtoacm., end hereby autho or repec.enutivu of this tiny to enter, need the
above-mernioned property for inspection purposes.
(We) agree to save. indemnify ate kap harmless the City of C.,mm, against
ludulaies,judgments, costa end npenses which may in any way ammeagmml .,it City
in consequence of the granting of this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON PoINT
ii TICE RQGUL NS.
VO19,#.k^ wgl X1-13-00
HAZARDOUS MAI'ERALS DISCLOSURE
Will the applicant m fusurt Wilding uccupant store m handle Id randeu. material
u def red by the Cupertino Municipal Cale. Chapter 9.11, and the HeilN and Sarmy
Craft, Section 25532(.)]
❑Yes [A No
Will the applicant or future building occupant use equipment or devices which
enact hawrdaw air mmusediwnu as defend by the Bay Arca An Quality Mansgw¢m
District?
❑ Y<s B No
1 have red the huardms mamiala mquircmau under Chapter 6.95 a dtc Cali.
foods Health & Safety Code, Sections 25505. 25533 moth 25534. 1 understand Nes if the
bac' d acumen h.vewenenl,thaio'nmymaporaibililymnaifytheeccupmt
o s U whit t ed inn or to' hasse.f4trific of
O:mr m euthori rm.gent Date
t WvoDwo2�5 _ MoNvPtfeNi S[CtJ
./ RAJA LeAYt4og
.Face c�+aubt
Sq. Ft. Floor Area
J o. O c
APR 13 2000 C
Py_
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing, material being
installed. If a roof is Installed without first obtaining an inspection
I aggree to remove all new materials for inspection. Applicant
u 5erstands and will comply with all non point source regulations.
Signature of Applicant Date
OFFICE
All roof coverings to be Class "B" or better